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PNEUMONIA

Dewi Kartikawati N.
Structure and Function
Gas Exchange
Changes Associated to Aging
recoil and compliance
AP diameter
functional alveoli
in Pa02
Respiratory defense
mechanisms less effective
Altered respiratory controls
More gradual response to
changes in O2 and Co2
levels in blood
Pneumonia Definition
An acute infection of the pulmonary parenchyma that is
associated with at least some symptoms of acute infection,
accompanied by an acute infiltrate on CXR or
auscultatory findings consistent with pneumonia
Pneumonia
The major cause of death in the world

The 6th most common cause of death in the U.S.

Annually in U.S.: 2-3 million cases, ~10 million


physician visits, 500,000 hospitalizations, 45,000 deaths,
with average mortality ~14% inpatient and <1%
outpatient
Pneumonia - Symptoms
Cough (productive or Chills/Sweats
non-productive)
Fatigue
Dyspnea
Headache
Pleuritic chest pain
Diarrhea (Legionella)
Fever or hypothermia
URI, sinusitis
Myalgias (Mycoplasma)
Findings on Exam
Physical:
Vitals: Fever or hypothermia
Lung Exam: Crackles, rhonchi, dullness to percussion or
egophany.
Labs:
Elevated WBC
Hyponatremia Legionella pneumonia
Positive Cold-Agglutinin Mycoplasma pneumonia
Chest X-ray

RUL LUL

RUL LUL
Lingula
RML
Lingula
LLL RM
RLL
L
LLL
RLL
Chest X-ray Pneumonia
Chest X-ray - Pneumonia
Chest X-ray -- Pneumonia
Types of Pneumonia
Community-Acquired (CAP)
Health-Care Associated Pneumonia (HCAP)
Hospitalization for > 2 days in the last 90 days
Residence in nursing home or long-term care facility
Home Infusion Therapy
Long-term dialysis within 30 days
Home Wound Care
Exposure to family members infected with MDR bacteria
Hospital-Acquired Pneumonia (HAP)
Pneumonia that develops after 5 days of hospitalization
Includes:
Ventilator-Associated Pneumonia (VAP)
Aspiration Pneumonia
Common Bugs for Pneumonia
Community-Acquired HCAP or HAP
Streptococcus pneumoniae
Pseudomonas aeruginosa
Mycoplasma pneumoniae
Staphylococcus aureus
Chlamydophila psittaci or
pneumoniae (Including MRSA)
Legionella pneumophila
Klebsiella pneumoniae
Haemophilus influenzae
Serratia marcescens
Moraxella catarrhalis
Staphylococcus aureus
Acinetobacter baumanii
Nocardia
Mycobacterium tuberculosis
Influenza
RSV
CMV
Histoplasma, Coccidioides,
Blastomycosis
Diagnosis of pathogen

Sputum Culture
< 10 Squamous Epithelial Cells
> 25 PMNs
Blood Cultures
Strep. pneumo urinary antigen
Legionella urinary antigen
HIV test?
Special Clues on Chest X-ray

Lobar pneumonia Strep. Pneumonia


Diffuse interstitial infiltrates Pneumocystis
RUL infiltrate Tuberculosis
Diffuse interstitial infiltrates Tuberculosis in
HIV
Treatment of CAP
Outpatient:
Macrolide (Azithromycin)
Fluoroquinolone (Levaquin, Moxifloxacin)
Doxycycline
Inpatient:
Beta-Lactam + Macrolide
Ceftriaxone + Azithromycin
Fluoroquinolone (Levaquin, Moxifloxacin)
For suspicion of highly resistant Strep. pneumoniae
Treatment of HCAP, HAP, VAP

Antipseudomonal cephalosporin (Cefepime,


Ceftazidime) + Vancomycin

Anti-pseudomonal Carbapenem (Imipenem,


Meropenem) + Vancomycin

Beta-Lactamase/Beta-Lactamase Inhibitor (Pip-Tazo


Zosyn) + Pseudomonal Fluoroquinolone (Cipro) +
Vancomycin

Aminoglycoside (Gentamycin, Amikacin) + Vancomycin


Pneumococcal Vaccine
What does it cover?
Protects against 23 serotypes of Strep. Pneumoniae (90%
of invasive pneumonia infections)
Who should get it?
Anyone over age 65
Anyone with chronic medical problem such as cancer,
diabetes, heart disease, lung disease, alcoholism, cirrhosis,
sickle cell disease, kidney failure, HIV, damaged spleen or
no spleen, CSF leaks
Anyone receiving cancer therapy, radiation, steroids
Alaskan natives and certain Native American populations
How often to get it?
Give second dose if >5 years from first dose if > 65,
cancer, damaged spleen, kidney disease, HIV or any other
condition lowering immune system function
Diagnostics

Pulse Oximetry
Pulmonary Function Tests

Chest X-Ray
Sputum Specimen and Cultures

Computed Tomography
(CT scan)

Bronchoscopy

Thoracentesis
Diagnostics: Pulse Oximetry
Measures arterial oxygen
saturation
Pulse oximetry probe on
forehead, ears, nose, finger,
toes,
False readings
Intermittent or continuous
monitoring
Ideal values: 95-100%
When to Notify MD
< 91%
86% (Medical Emergency)
Diagnostics: Chest X-Ray
Screen, diagnose,
evaluate
treatment

Instructions: No
metals/jewelry
Diagnostics: Chest X-Ray Cont.

Nodule

Infiltrates

Posterior Anterior View Left Lateral View


Diagnostics: Sputum Specimen
To diagnose; evaluate treatment
Specimen: ID organisms or abnormal cells
Culture & Sensitivity (C&S)
Cytology
Gram stains
(e.g. Acid Fast Bacilli)
Diagnostics: Computed Tomography:
CT Scan
Images in cross-
section view
Uses contrast agents

Right upper Lobe


Diagnostics: Bronchoscopy

Procedure Care/Instructions:
Diagnose problems and assess NPO 6 -8 hrs prior
changes in
bronchi/bronchioles Sedation during procedure
Performed to remove foreign Post Procedure:
body, secretions, or to obtain HOB elevated
specimens of tissue or mucus
for further study Observe for hemorrhage
NPO until gag reflex returns
Diagnostics: Pulmonary Function Test
(PFTs)
Evaluate lung function

Observe for increased


dyspnea or
bronchospasm

Instruction: No
bronchodilators 6 hours
prior
Diagnostics: Thoracentesis
Specimen from pleural
fluid
Treat pleural effusion
Assess for complications

Post-Procedure care:
CXR after procedure

Positions
Sitting on side of bed over bedside table
chest
elevated
Lying on affected side
Straddling a chair
Pneumonia: Complications

Hypoxemia
Pleural
effusion
Atelectasis
Atelectasis Pleurisy

Pleurisy

Pleural Effusion
Toxic sprinkles anyone?
Any Questions?

The definition of hope is you do still believe


when it is hard.

-President Barack H. Obama

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